Department of Neurosurgery, Ninewells Hospital, Dundee, UKUnited Kingdom
Department of Radiology, Ninewells Hospital, Dundee, UKUnited Kingdom
Department of Accident and Emergency, North Manchester General Hospital, Manchester, UKUnited Kingdom
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Incidental durotomy (ID) is a term used to describe unintentional opening of the duramater during spinal surgery. Although, commonly referred to as dural tear; most recent scholars are circumventing the use of the latter term, as it could imply an element of carelessness when none were necessarily present. Therefore, ID, unintended durotomy, unintentional durotomy or simply just dural opening, have been recommended to replace the term dural tear. The reported incidence of ID of spinal surgeries ranges from 0.1-13.7%. Despite being one of the most common complications of spinal surgery, it remains often underreported because of the lack of morbidity in the most of cases. ID is often associated with cerebrospinal fluid (CSF) leakage from the subarachnoid space through the dural defect.
Keywords: unintentional; circumventing; durotomy
turned to normal. Figure 3 shows a patient with ID, treated with
open repair and flat bed rest, with good outcome. Even promi- Despite the fact that a period of flat bed rest following ID and
nent collections managed with dural sealing agent; have been CSF leak is commonly advised, it is by no means accepted as a
successfully treated without flat bed rest (Figure 4). However, standard practice. Although, there is a clear need for first class
we do come across occasional patients who have had unfavourevidence to address the topic; yet, the current available evidence
able outcome with persistent symptoms despite open repair and supports early mobilisation following sufficient dural repair. We
bed rest, we have successfully treated such patients with glue understand the difficulties in running such trial as standardizing
injection, it is often important to localise the site of communicathe size and site of the durotomy, the underlying spinal pathol-
tion in such patients (Figure 5).
ogy, patients’ comorbidities/healing potentials, and closure tech-
Figure 5. CSF Leak Following ID. T2 Sagittal (a) Axial (b) Images (Above) Showing a Large CSF Collection (Black arrows). Site of Communication Shown by White Arrow in (b). Initially Patient had an Unsatisfactory Outcome Following Conservative Treatment. Subsequently Treated with Glue Injection. T2 Sagittal (c) and Axial (d) Images (Below) Showing Significantly Reduced Collec-
tion (Black Arrow in d) Following Glue Injection.
niques might be challenging to say the least.
3. Grannum S, Patel MS, Attar F, Newey M. Dural tears in pri-
mary decompressive lumbar surgery. Is primary repair necessary
Different methods for achieving satisfactory dural clofor a good outcome? Eur Spine J. 2014; 23(4): 904-908. doi:
sure exist, with promising results of the advancing technology 10.1007/s00586-013-3159-9
for dural sealing agents especially for durotomies where prima-
ry suturing is not thought to be feasible or technically possible 4. Raskin NH. Lumbar puncture headache: A review. Head-
without significant collateral damage.
ache. 1990; 30(4): 197-200. doi: 10.1111/j.1526-4610.1990.
hed3004197.x
Long periods of flat bed rest does not decrease the rate
of complications, in fact early patients mobilisation potentially 5. Eismont FJ, Wiesel SW, Rothman RH. Treatment of dural
reduces the length of hospital stay, medical complications and tears associated with spinal surgery. J Bone Joint Surg Am. 1981;
the overall cost on the health system.
63: 1132-1136.
6. Hodges, Scott D, Eck JC, Covington LA. Management of in-
cidental durotomy without mandatory bed rest: A retrospective
The authors declare that they have no conflicts of interest. review of 20 cases. Spine. 1999; 24(19): 2062-2064.